Is Nursing a Profession?
Submitted by Laura Steadman EdD, MSN, CRNP, FNP-BC
Laura Steadman, Ed.D, CRNP, MSN, RN
Gary Milligan, DNP, MSHA, APHN-BC
Is nursing a profession? This question has been the subject of discussion for a number of years. To understand the basis of the debate, a description of what comprises a profession must first be explored. A profession is described as an occupation in which specialized training is required (Blais & Hayes, 2016). Ritchie and Gilmore (2013) describe a profession as requiring prolonged training and formal qualifications. A profession ensures competent performance of individuals within its ranks (ANA, 2021). Typically, within the US, professions are distinguished by certain specific characteristics; these include, but are not limited to formal educational requirements, autonomy of practice, adherence to an established code of ethics, expansion of the level of knowledge, and a common culture and values present among members (Joel & Kelly, 2006). The purpose of this paper is to explore ways in which nursing meets these criteria of a profession.
Institutions of Higher Education
A profession must have a clear educational pathway into the practice and a constantly growing body of knowledge within institutions of higher learning (Blais & Hayes, 2016). Currently, there are many pathways for nursing education, ranging from two-year degree programs to bachelor to direct-entry masters and doctorate programs. Regardless, programs at every level of study share the common pedagogical goal of providing students with the practical knowledge and theoretical basis to deliver safe and effective health care as integral members of the inter-professional healthcare team. Despite the variety of nursing programs and the range of advanced degrees they offer, all students have their basic professional nursing skills assessed by the National Council Licensure Exam (NCLEX). All students must pass the NCLEX before entering the workforce or progressing towards more advanced degrees; professional standards are clearly established, and all prospective nurses are held to a uniform standard of proficiency. Successful completion of the NCLEX exam permits any Register Nurse (RN) to practice under the nursing practice act of an individual state regardless of the level of education attained, however, more and more healthcare institutions are choosing to give RNs with a Bachelor of Science in Nursing (BSN) priority in the hiring process. This is another indication the BSN is progressing becoming the level of entry for nursing practice.
Nursing as a profession is constantly expanding its scope of practice and challenging its workforce to continue its education. The impetus for further education comes from external sources, such as the Institute of Medicine (IOM) (2013) who recommends an 80% increase in the number of associate degree prepared nurses pursing a bachelors level education by 2020 (Sheetz, 2012) and from professional nursing groups, such as the American Nurses Association (ANA) which has been advocating the baccalaureate degree as the minimum degree required for entry into nursing practice for over forty years (Smith, 2010). Additionally, organizations such as the American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) advocate for nursing education and of advancing the overall scope of nursing practice. Through advanced education, professional nurses, all held to the initial NCLEX standard, can be prepared to fill a larger number of more focused roles, extending from dialysis management, geriatric care to advanced practice roles with prescriptive powers.
Each specialization includes its own additional professional standards and certification exam, furthering the uniform standards for all nurses. Of course, with multiple levels of educational preparation with which one may enter the practice of nursing, it can be argued that nursing does not meet the educational requirement identified by Joel and Kelly (2006).
One specific quality of a profession is that a profession operates independently with legislature in creating policy and it supervises its own professional standards and the practices of its practitioners (Blais & Hayes, 2016). Nationwide, individual state boards of nursing have the autonomy to determine nursing’s standards of practice, allowing nurses to operate autonomously within their established scopes of practice. In some states, advanced practice nurses can embark on their own practices. Over time, individual state nurse practice acts have been steadily granting nurse practitioners increasing levels of autonomy within their spectrum of practice (Catalano, 2009). The practice of medicine is an example of the development of a profession, as medicine developed into a profession the autonomy of physicians continued to expand. Nursing will see a growth in the level of autonomy in everyday practice as nursing becomes more recognizable as a profession.
The ability to determine one’s course of action is often identified as a characteristic of a profession. In the nursing work environment, this freedom could best be translated as empowerment. Zurmehly, Martin, and Fitzpatrick, in a 2009 study of nurses’ intent to leave the profession, found that having a sense of empowerment was the single-most significant factor in a nurse’s dedication to continue in nursing. The study concluded that improvements in nurse retention firmly required implementations specifically designed to increase the sense of nursing empowerment. Other studies found that nurses must feel empowered in the workplace (Mudallal, R. H., Othman, W. M., & Al Hassan, N. F. (2017). Clearly, at least internally, nurses see themselves as professionals.
While the Zurmehly et al. (2009) study focused only on registered nurses, it is also of note that even advanced practice nurses have varying levels of freedom or autonomy in their practices. For instance, nurse practitioners in some states must practice under the supervision of a physician and have a collaborative practice agreement on file with their respective state board of nursing. According to Peacock, Hernandez (2020), nurse practitioners should practice to full scope of their advanced education level. While this is not the case in all states, until freedom of action is uniformly applied to all nurses according to their educational preparation, it can be argued nursing lacks the full range of freedom of practice to be considered as a profession.
Code of Ethics
Another quality identified by Joel & Kelly (2002) is that a profession must have an established code of ethics that guides the profession as well as defines the relationship between professional and client. Nursing relies on the Code of Ethics established by the American Nurses Association (ANA) as ethical standard for conduct that guides professional practice. There are nine provisions to the Code of Ethics. These provisions codify the fundamental values of nursing, establish the boundaries of nursing duty, and articulate the ethical responsibility of the nurse (ANA, 2008). These are the guiding principles, obligations, and commitments of the nursing profession. Ethics in health care includes the rights, responsibilities, and obligations of professional and clients. The Code of Ethics directs the goals, values, and ethics for nurses to uphold (Matthews, 2012).
With a defined code of ethics, the nurse is able to recognize and face ethical challenges for a complex patient population (Ulrich, et al., 2010). The nursing profession is never independent from current culture and context of professional ethics (Kangasniemi, Stievano, & Pietila, 2013). The Code of Ethics holds the nurse accountable for his or her actions along with those of the individuals to whom the nurse delegates tasks involving patient care (Blais & Hayes, 2011). Fowler, (1989) describes the Code of Ethics as assurance to the public that nurses are proficient and capable of providing safe and effective care. The nurse adheres to the Code of Ethics as a framework to guide in decision making. Nurses rely on ethical codes and standards to guide care, understanding these standards result in the most positive patient outcomes (Shaw & Deganzon, 2008). Following standards ensures each professional abides by a defined set of principles that protect the integrity of the profession.
Joel and Kelly (2002) require a profession to engage in enlarging its body of knowledge. In addition, this body of knowledge must be well defined and organized in order for it to be applied within the complex healthcare environment. Given the current speed at which healthcare is increasing in complexity, nursing is necessarily a constantly changing profession with all nurses having an obligation to remain current and knowledgeable regarding advancing health care practices. Nurses must possess a strong knowledge base developed through evidence-based practice, continuing education, skill validation, and annual competency reviews. These practices assist nurses in broadening knowledge and allow professional nursing organizations to maintain uniform standards, as the nurse’s role evolves. Current nursing educational programs provide tools necessary for nurses to stay abreast of the advancement’s healthcare. Many nurses are encouraged to continue their education (Russell & Beaver, 2013).
The ANA holds the view that the registered nurse is responsible for maintaining clinical competency through continued education (ANA, 2008). Most nurses are required to accrue a number of continuing education hours before each license renewal cycle. This continued education is so important that many health care facilities offer tuition reimbursement to encourage their employees to continue their education. As nursing requires a broad-based education encompassing many health care disciplines, continued learning in nursing satisfies another attribute of the profession criteria by ensuring a current growing foundation of knowledge that protects the patient from risk of harm (Robinson, 2013).
Culture and Norms
Joel and Kelly (2002) explicitly identify the existence of a shared culture as well as a set of norms within a profession. Nursing tends to attract those who have a desire to provide care to people. This desire manifests in multiple forms; for example, there are nurses who prefer to care for babies or children, nurses who desire to care primarily for cancer patients, and nurses who wish to care specifically for women. Although nurses may choose to focus on providing care for specific patient population, the common bond that holds nurses together is the desire to provide care to another. An occupation or job may be described as providing labor, completing a task, or delivering a service in exchange for remuneration. A profession is similar in that a service is provided for remuneration, but also includes a shared culture. As all specialties of nursing encompasses a passion for the increasing well-being of patients, a desire to provide specialized skills, and a desire to grow as a nurse.
The American Association of Colleges of Nursing (AACN) (2008) a desire to enable patients, families, and communities to achieve an optimal health status, a core value of nursing. This goal is accomplished through the application of altruism, excellence, caring, ethics, respect, communication, and accountability. These characteristics are ingrained within the culture of nursing and considered a norm for the nursing profession. The Gallup Poll (2022) has consistently found the nursing profession to be ranked as the number one trusted profession in its annual polls of Americans. Nursing has been ranked as the most trusted profession by 80% of Americans since 2005. This ranks nurses above pharmacists, medical doctors, and members of the clergy. Indeed, the nursing culture has promoted a norm of caring which is recognized by the public and elevated the nursing profession to the number one most trusted profession.
The development of a culture of caring which encompasses the set of norms including altruism, excellence, caring, ethics, respect, communication, and accountability begins within the confines of nursing education. Undergraduate nursing curricula emphasize caring as a basic tenant of nursing education. The art and science of nursing involves all dimensions of patient care; a focus on the patient’s needs is paramount for the nursing student as the student develops a connection with the patient (Fahrenwald et al., 2005). A connection to the patient is part of the initiation of compassionate appropriate care. The establishment of core values in the education of a student nurse is part of the advancement of a strong caring culture in the nursing profession.
Although the question of whether nursing is a profession may not be settled, nursing possesses qualities that entrust education to institutions of higher learning, has established policies for practitioners while allowing the nurse to function autonomously in practice, has a code of ethics in which to practice and has clear set of educational standards for continuing education. So, the discussion is particularly important when it is viewed from the perspective of a RN with an ADN degree who is enrolled in a RN to BSN program, that is, the nurse is seeking to increase the current level of education under which he or she practices.
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